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BUILDING DIVISION PERMII'*&W
BUILDING ADDRESS:
21831 SAN FERNANDO AVE
OWNER'S NAME:
ARCHITECTIENGINEER:
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and erten.
License Class LJc. R
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.3, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (SSW).
[11. as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon, and who does such worst himself or through his
own employees, provided that such Improvements are not intended or offered for ask. If.
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that be did not build or Improve for purpose of
sale.).
J�Ll, as owner of the property. am exclusively contracting with licensed contractors to
wtruct the project (Sec. 7044, Business and Professions Code:) Mw Contracoea U.
cense LAW does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License LAW.
❑ I am exem t on B & P C for tido reason
-�/ 1V
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum for Worker's Compen.
sation, as provided for by Section 3700 of the IJbor Code, for the performance of the
work for which this permit Is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit Is for one hundred dollars ($100)
Or lest)
1 oxnify that in the performpp of the work for which this permit is issued, l shall not
employ
loy a�person in anylfighner — as to romc)A ject to the Workers' CompensW on
Lawsof
App icanI gT`
N P CANT:!f, aflcr making this Certificate of Exemption, you should
bee lubject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
do work for which this permit is issued (Sec. 3097, Civ. C.)
L.endees Name
L.endces Address
1 certify that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authodre representatives of this city to enter upon the
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, Judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permit.
t
LICANT UND ANDS AND WILL C LY WITH ALJ. NON -POINT
RC
urs of Appii =t/C tone Dao
HArARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by site Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
0Yes 165No
Will the applicant or future building occupant use equipment or devices which
emelt hazardous air contaminants as defined by the Bay Ares Air Quality Management
District?
Cl Yes No
1 have orad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not curmntlant that h is my respo Illy o notify ft occupant of the
require m r met prior o issuan Certifies of Oce c .
NEW S.F. DWELLING
LIVING SPACE 3639
GARAGE 674 SQ.FT.
Sq. Ft. Floor Area
rrnmtt NU.
02110158
PERMrr ISSUE DATE
02/20/2003
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLC7 Q PLS
Job Description
(2 STORIES)
SQ.FT.
5.4 trr GAS TEST
0 1 FINA, PLUMBING_
=91-
Re -roofs 514 keINAL PUBLIC WORKS
Type of R(>bD2 - ROOF PLYWOOD NAIL
603 ROOF BATTENS
All roofs sfikbe inspIRMEprillRo i*QEadM§l@Aaterial being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All rnnf rnvurar rte rn ho !'leen �rl]r, ..� L_..__